SESSION TITLE: Pulmonary Vascular Disease Case Report Posters
SESSION TYPE: Affiliate Case Report Poster
PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM
INTRODUCTION: Pulmonary tumor emboli are a rare cause of death. Difficulty in diagnosis contributes to low incidence, however they are found on autopsy in up to 26% of patients dying from cancer.
CASE PRESENTATION: A 24-year-old female presented with increasing shortness of breath, nonproductive cough, and chest pain for 1 week. Before admission she syncopized. The patient had ovarian cancer five years prior that was treated with left salpingo-ophrectomy and chemotherapy. She was lost to follow-up. In the emergency room, vital signs were as follows: pulse rate 127, respiratory rate 32, afebrile, blood pressure 120/70 with oxygen saturation of 91% on room air. Physical exam showed mild respiratory distress with lungs that were clear to auscultation. ABG revealed pH 7.48/PaCO2 33/PaO2 88. Electrocardiogram showed sinus tachycardia with T-wave inversions in the anterior leads. Chest radiograph was normal. CT pulmonary angiogram showed no pulmonary emboli, an enlarged right heart and pulmonary artery, and a 1 cm nodule with tree-in-bud pattern in the right lung. Thirty-six hours after admission, she developed increasing dyspnea, hypoxemia and tachycardia. She lost consciousness and had respiratory arrest requiring endotracheal intubation. She developed hypotension. Transthoracic echocardiogram showed massive right heart dilation with septal compression consistent with severe cor pulmonale. There was increased RV free wall thickness and PASP could not be estimated. She was started on norepinephrine and inhaled nitric oxide, however suffered an asystolic cardiac arrest from which she could not be resuscitated. The autopsy showed carcinomatous pulmonary emboli of ovarian cancer origin, an enlarged right ventricle, and increased RV wall thickness.
DISCUSSION: This case highlights the importance of clinical suspicion for pulmonary tumor emboli in a cancer patient with unexplained dyspnea and hypoxemia with a normal chest radiograph and no evidence of thromboembolic disease on CT angiogram.
CONCLUSIONS: Diagnosis is challenging. Ventilation-perfusion scan may show subsegmental mismatched defects, a nonspecific finding. There are reports of diagnosis with PA catheter cytology aspiration. Pulmonary tumor emboli represent metastatic disease. Treatment is not effective. Attempts may be made to reduce RV afterload with nitric oxide and diuresis. Also by increasing RV contractility with inotropes. Fibrinolytics are ineffective.
Reference #1: Roberts KE, et al. Pulmonary Tumor Embolism: A Review of the Literature. Am J Med. 2003; 115:228-232
DISCLOSURE: The following authors have nothing to disclose: Annamaria Iakovou, Zubair Hasan, Hua Guo, Farnaz Tahmasebi, Harly Greenberg, Paul Mayo
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